Getting Paid Under Scrutiny

In between hurricanes and frightful traffic, I have been fighting for money that other people want to take away from my clients.  My first intention was to show  you the language typically used in the denials I have been seeing from the Zone and the MACs.  Then it occurred to me to show you what was written when the claims were allowed.  This might be of greater value.

Medicare guidelines for reimbursement have been met. Patient received physical therapy services due to recent fall and weakness. Skilled nursing services for medication changes and observation and assessment of disease process. Therefore, it is allowed.

Medicare guidelines for reimbursement have been met. The patient required medication changes related to her hypertension and hyperkalemia. Therefore, the episode is allowed.

Medicare guidelines for reimbursement have been met. The patient had multiple medication changes related to blood pressure fluctuations that required monitoring. The skilled nursing services are approved.

Skilled nurse visits allowed due to patient requiring skilled nursing assessment and observation. Pt had upper respiratory symptoms and was started on prednisone and phenergan expectorant cough syrup. Documentation meets Medicare criteria for reimbursement.

There were plenty other claims paid.  Some were paid because the patient went into the hospital for heart failure of renal disease.  I did not use those as an example because it is not sound clinical practice to induce an exacerbation for payment purposes.

The difference between these claims which have been allowed and those which are denied begins with the nurse in the home.  Three things must happen in order to rightfully claim that an exacerbation has occurred.

1. The patient’s condition must change.
2. The nurse must communicate the changes to the MD
3. The plan of care must change as a result of the changes

The nurses whose documentation resulted in payment above did not get a blood pressure of 160/95 and write it off to the fact that the patient just walked down the driveway to get his mail and ignore it.   They don’t just assume that everyone has allergies this time of year and make a note to check on the patient again next week.  These nurses may be very friendly but they do not make visits that only social in nature.  They take the time to communicate changes, get orders and document.

More important than surveys and payment is that this careful attention to patients results in better care.

The parameters that are not mandated but are shown to be good practice when writing care plans can be an invaluable tool.  Everything else aside, if your patient exceeds parameters by only a fraction and you do not call the MD, you have not followed orders and that results in a survey deficiency.

When you communicate with the physician, have all the information required.  What has the blood pressure been over the past several weeks?  Is there anything else going on with the patient?  Were there any med changes?

Here is a visit note written in a claim that was denied.

I am horrified that one of my peers actually accepted money from her employer for this level of nursing.  It does not require the skills of a licensed nurse to tell the patient to take meds exactly as prescribed.

Agencies can implement all kinds of strategies, hire the best consultants (if we’re available), set arbitrary visit rates and lengths of stay but unless the nurses visiting the patient take the time to really take care of the patient, it is all for naught.

But if you have good nurses, we can and will see you through a little regulatory scrutiny.

Be sure to drop me an email if you are getting any strange ADRs.  I am particularly interested in those with a reason code of 5Z5NP.